Ick Award

Here’s a potent argument in support of those Oh-So-Annoying JCAHO regulations – outpatients getting clinic-based chemotherapy came down with a rare, nasty blood infection. Clinics aren’t covered by those irritating rules and regulations. Perhaps the only way anyone really recognized the source of these infections is because the germ was sooo unusual. Alcaligenes is a germ that can grow even in sterilized saline. Yeesh. It was found both in the blood and in the semi-permanent Central Venous Catheters (CVC) of 12 people – keep in mind that a chemo central venous catheter goes straight to your heart. Now that’s a serious infection. So how was this nasty germ spread into patients’ blood? Brace yourself…

“Of the 4 staff members at Office B who regularly accessed CVCs; inserted peripheral intravenous catheters; collected blood; and prepared or administered chemotherapy, flushes, or intravenous medications, only 1 was a registered nurse who had a California state license. The 3 nonlicensed staff members were reported to have received nursing training in their native country but did not have documented formal training or education. One nurse wore artificial fingernails but had removed them before hand culture samples were collected; thus, the fingernails were unavailable for culture. The following breaches in infection control were noted: intravenous catheters were inserted by persons not wearing gloves; unlabeled, prefilled syringes were stored in the hood; no documentation of hood cleaning was found; open, multidose heparin vials and saline bottles, some undated, were found throughout the facility; nonhygienic material was stored in the chemotherapy medication preparation hood; and failure to wash hands between patients was noted. No pharmacists were employed at Office B. No documentation of staff training and evaluation for chemotherapy preparation or infection control competency was available.”

The CDC investigators’ conclusions? “We observed multiple breaches in infection control at Office B: use of unlabeled, prefilled syringes, poor hand hygiene, and lack of glove use. The CVC of case-patient 1 may have been flushed by using the same syringe and needle inserted into multidose vials, causing contamination of the vials. Another possible route of contamination is through artificial fingernails. A cluster of Serratia marcescens and A. xylosoxidans bacteremia cases linked to multidose heparin vials contaminated by a nurse with artificial fingernails has been reported;[22] however, the artificial fingernails from the nurse at Office B were unavailable for testing. We suspect that multidose vials were contaminated with A. xylosoxidans and subsequently used on other patients from November 12 through December 18, 2001, when all case-patients had overlapping visits at Office B and received CVC flushes. A culture from an open, supposedly sterile saline bottle grew B. circulans, which suggests possible breaches in infection control. Multidose heparin and saline vials have been reported as the cause of outbreaks of hepatitis C,[23,24] S. marcescens,[25] and Pseudomonas aeruginosa[26] infections.”

This latest disease outbreak comes on the heels of last May’s hepatitis C outbreak in Nevada from an outpatient procedure clinic where employees were reusing syringes. Perhaps, as more and more invasive procedures are moved to outpatient clinics, the appropriate regulations ought to follow.

What Can You Do To Protect Yourself?

1) Before you commit to a procedure, or a long-term course of meds as invasive as chemo, ask about the credentials of the people involved. Are they all R.N.’s? Do they have licenses, and credentials up-to-date in this country?

2) Ask if the clinic follows JCAHO regulations. Ask if there are any infection control procedures (and who’s in charge of them – if there’s a name, especially a nurse’s name, then it’s probably being done).

4) Nix the artificial nails. If your nurse (or doctor) has them, gently point out the infection-control issues, or speak to a supervisor to register your concerns.

5) If you have a choice between equals, consider choosing an outpatient clinic affiliated (and sharing staff) with a nearby big hospital – training, licensing and invasive procedure protocols are more likely to be standardized.